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A 64-Year-Old with a Solitary Pulmonary Nodule
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A 64-Year-Old with a Solitary Pulmonary Nodule
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Upload Date:
2022-02-28T00:00:00.0000000
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Language: EN.
Segment:0 .
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CATHY: Hi. Welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy. And I'm Charlie Wiener and we're coming to you from the Johns Hopkins School of Medicine.
CATHY: Welcome to Episode 27: A 64-year-old with a solitary pulmonary nodule.
CHARLIE: Okay, this segment is going to have two questions regarding this problem, and it's an important topic to discuss. The first question reads: A 64-year-old man seeks evaluation for a solitary pulmonary nodule that was found incidentally on a chest CT scan. Which are the following statements regarding a solitary pulmonary nodule is true? Option A reads, a lobulated and irregular contour is more indicative of malignancy than a smooth contour. Option B says, about 80% of incidentally found pulmonary nodules are benign.
CHARLIE: Option C says, absence of growth over a period of 6-12 months is sufficient to determine whether a solitary pulmonary nodule is benign. Option D says, ground-glass nodules should be regarded as benign. And option E says, multiple nodules indicate malignant disease. So Cathy, what do you think?
CATHY: Most solitary pulmonary nodules are benign and many are actually too small to be diagnosed by biopsy or non-specific in nature. In fact, over 90% of incidentally identified nodules are benign in origin. So, this excludes option B because it's actually higher than 80%. Of the traces listed I would say that A is the correct one that lobulated and irregular contours of the nodule are more indicative of malignancy than if a nodule had smooth borders.
CHARLIE: What about the growth rate? That's mentioned in one of the answers also.
CATHY: So, rapid doubling time is more likely to signal a malignancy compared to a slower doubling time. But 6-12 months really isn't long enough to follow. In order to effectively rule out a malignancy, you really should follow the lesions for a period of at least two years and demonstrate no growth, especially in a patient like ours who is at high risk for lung cancer. If the lesion were to remain stable for two years, it's more likely that it's benign, although there are some slow growing tumors, for example bronchoalveolar cell carcinoma that can have slower growth rates and these can increase in size even after two years.
CHARLIE: So, it's important as you look at your serial CT scan, it's important to be very, very careful in measuring the size of these things and having reproducible techniques so that you can actually look for slow growing nodules. What about the appearance on CT, or if you see multiple nodules?
CATHY: Option D asks about the ground-glass appearance and that doesn't help us distinguish between malignant or benign nodules. When multiple pulmonary nodules are defined, this most commonly represents prior granulomatous disease from healed infections particularly if the nodules are calcified. So, that really rules out option E and option D. And if multiple nodules are malignant in origin this usually indicates either metastases to the lungs, but it can also be either simultaneous lung primary lesions, or less common even satellite lesions from one primary lung cancer.
CATHY: Other features that would concern me for a malignant disease are is if the nodule has a size greater than 3cm, or if there's eccentric calcification.
CHARLIE: So again, close observation of the nodules is important because central calcification typically represents a benign process, whereas eccentric calcification suggests possible malignancy. Okay, well let's get back to these questions and talk more about our case. Our patient, a 64-year-old man presented to the emergency department for shortness of breath and chest pain. A CT pulmonary angiogram to rule out pulmonary embolism was negative for pulmonary embolism however, showed a 9mm solid nodule in the periphery of the left lower lobe.
CHARLIE: He had no enlarged mediastinal lymph nodes and he previously had had a CT scan three years ago when he presented to the ER with similar complaints and notably that CT had no peripheral lung nodules and no lymph node abnormalities.
CATHY: So, we hear that this is a solid nodule that's grown within three years, so this has me more concerned about a malignancy. Can you tell me more about his history?
CHARLIE: Okay, he's a current smoker of two packs of cigarettes daily and he's done so since the age of 16. He generally reports no functional limitations related to respiratory symptoms, he's had PFTs within the last year and his FEV1 is 88% predicted and his forced vital capacity is 92% predicted. His diffusion capacity is 85% predicted. The question now reads: what is the best next step in the evaluation and treatment of this patient?
CHARLIE: Option A says, perform a bronchoscopy with biopsy for diagnosis. Option B says, perform a combined PET-CT to assess for uptake in the nodule and assess for lymph node metastases. Option C says, perform a follow up CT scan in three months to assess for interval growth. Option D reads, refer the patient to radiation oncology for stereotactic radiation of the nodule. Option E reads, refer the patient to thoracic surgery for video-assisted thoracoscopic biopsy and resection of the lung nodule if malignancy is diagnosed.
CATHY: The first point to make here is that the patient's at high risk for lung cancer and is an appropriate patient to receive lung cancer screening with low dose CT. We're passed this point now though, but we hear that this patient has a long smoking history with a new nodule that wasn't apparent by chest CT imaging three years ago. And as I said before, we're most worried about malignancy. Because of the high mortality rate of lung cancer and the potential for cure at an early stage, we would really want to try and diagnose it early.
CHARLIE: So, would you want to go with additional scanning, try for a diagnosis, or go straight for treatment?
CATHY: Well, with the size being 9mm and the appearance within a few years, I would go with definitive diagnosis for a potential lung cancer. Other factors that make me concerned about lung cancer in this patient are his age, his long smoking history and we also hear about some underlying lung disease although at this point it's not very bad. A PET-CT is not unreasonable to do but can be difficult to detect cancer, or any FDG-avid nodule when the size is less than 1cm. In this case we hear that the nodule is small and we also don't hear about any pathologically enlarged lymph nodes so the utility of PET-CT right now would be pretty low.
CATHY: A repeat CT scan to assess for interval growth would only be appropriate I think if the patient declined further work up at this time.
CHARLIE: Okay, so you do point out though that if there had been some enlarged lymph nodes, or if the primary nodule was bigger, maybe a chest CT-PET would be reasonable, but in this case because of the small size we're not going to do that. So, in that case how would you go about diagnosing this?
CATHY: Well, I would go with surgery. So, we hear about bronchoscopy as an option, but that may not provide a good yield because the lesion is very peripheral in origin, it may be hard to get to, and a negative biopsy for malignancy would not be definitive. Percutaneous needle biopsy with CT guidance could be an option, or surgical biopsy with definitive resection is also possible and those would be the best options. So, I would go with option E for this answer, refer the patient to thoracic surgery.
CATHY: And this could really be diagnostic and curative in one step.
CHARLIE: Why not go straight to treatment with radiation oncology?
CATHY: That's not appropriate in the absence of a tissue diagnosis of malignancy, and in this case we have other reasonable alternatives first.
CHARLIE: And also as you pointed out the resection could be cured if this is an early stage I cancer.
CATHY: Right and then you wouldn't need radiation at all.
CHARLIE: Okay, so the teaching point in this long and complicated case is that solitary pulmonary nodules are usually not malignant. However, in a high-risk patient, or in a patient who has a new appearance of a nodule, then malignancy should be suspected and the diagnostic evaluation will depend on the size, the location, and the characteristics of the nodule.
CATHY: And for more information about this, you can read Harrison's chapter on Oncology and the other reference that we'll send you to are the Guidelines on Management of Incidental Pulmonary Nodules that's put out by Radiology, in the journal Radiology Volume 284 No.1 and the most recent publication was in July of 2017. ♪ (music) ♪